1 Min In OTC
Bookmark
Record learning outcomes
Around a third of the UK population lives with a musculoskeletal condition, with many finding it has a major impact on their lives
Last month, the Nuffield Foundation and Versus Arthritis announced £1.94m in funding for new research to improve work and wellbeing for people with musculoskeletal conditions. These conditions have a profound impact on society and the economy, leading to 28.4 million lost working days a year.
Chronic pain conditions, such as arthritis and back pain, are complex and can be difficult to manage. While research is focusing on finding new pharmaceutical treatments, medicines can have significant side effects and/or carry a risk of addiction, and they don’t work well for everyone with chronic pain. The new research projects will ensure that those with lived experience are involved at every stage, to make a real difference for people with these conditions.
“Many of the issues linked to living with a musculoskeletal (MSK) condition, such as the inability to work, strain on mental health, deprivation or social exclusion, can’t be addressed by medical treatments alone,” says Dr Sarah Rudkin, head of research strategy and growth at Versus Arthritis. “More research is needed to understand the social, economic and psychological reasons why people with MSK conditions are more at risk of these issues and, crucially, what can be done to prevent this, so that we can better support people to live well with their condition.”
A growing problem
According to the report The State of Musculoskeletal Health 2021, published by Versus Arthritis, over 20 million people in the UK (around a third of the population) live with an MSK condition such as arthritis or low back pain. Chronic pain is the most common symptom, but people with arthritis can also experience high levels of fatigue, stiffness and loss of mobility and dexterity. Together, these symptoms can have a significant impact on their lives.
Osteoarthritis is the most common form of arthritis, affecting around 8.5 million people in the UK. It’s particularly common in women, people living in deprived areas, people aged 45 and over, and people living with obesity. Inflammatory arthritis is less common than osteoarthritis, but affects a wider age group.
Over 430,000 people in the UK have rheumatoid arthritis, around 100,000 people have psoriatic arthritis, and around 12,000 children have juvenile idiopathic arthritis. In addition, 10 million people in the UK have back pain and 1.7 to 2.8 million people have fibromyalgia.
A network of support
In May 2022, Versus Arthritis highlighted that using medicines alone doesn’t address key issues linked to chronic pain as affected individuals need a complex network of support that covers mental health, physical activity, community, peer support and healthy employment, and rigidly sticking to an over-medicalised approach will do little to increase their chances of living well.
Almost five in 10 people with long-term joint and muscle pain in England take five or more medicines on a regular basis. A Versus Arthritis survey found that over eight in 10 people with joint and muscle pain think having access to other management approaches would have a positive impact on their quality of life. Three in 10 people surveyed weren’t satisfied with the pain relief they achieve with their current treatment plan, and four in 10 said the top thing that would have a positive impact on their life would be if healthcare professionals treated all their conditions and symptoms together, rather than separately.
Many people with MSK conditions have other medical conditions as well, and these often need to be taken into account when creating a management programme. People with rheumatoid arthritis or gout, for example, are at a higher risk of heart disease and stroke, due to the higher levels of inflammation in their body.
Gout is a common form of arthritis that affects one in 40 adults in the UK. It’s caused by high levels of uric acid, which triggers joint inflammation. In August 2022, research carried out at the University of Nottingham in collaboration with experts at Keele University found that the risk of heart attacks and strokes temporarily increases in the four months after a gout flare. “People with recurrent gout flares should be considered for long-term treatment with urate lowering treatments such as allopurinol,” says Professor Abhishek Abhishek from the School of Medicine at the University of Nottingham.
“People with gout should be encouraged to adopt a healthy lifestyle with appropriate treatment of conditions such as high blood pressure, high cholesterol, obesity and diabetes to minimise their background risk of heart attack and stroke.”
“Many of the issues linked to living with a musculoskeletal condition... can’t be addressed by medical treatments alone”
Alternatives
According to NICE commonly used painkillers such as paracetamol offer little to no evidence that they provide relief from chronic pain, and in some instances can do more harm than good. .
Consultant rheumatologist Dr Rod Hughes comments: “While use of simple analgesics and NSAIDs can be reassuring and effective for those with muscular and joint pain, both groups of medicines may have side effects. For example, constipation and headaches can occur with some analgesics, and indigestion and peptic ulceration with NSAIDs.
As well as this, many commonly used analgesics such as NSAIDs and opioids are metabolised through the liver, and although damage to the liver is rare it can happen. To avoid the risk altogether, I always encourage patients to take as few of these painkillers as possible and to look for safe natural supplements that may cut down the need for stronger painkillers.”
Natural supplements are playing an increasingly important role in the treatment of a range of chronic conditions, and many individuals with OA or other joint problems have turned to these remedies in an effort to find symptom relief.
Dr Hughes adds: “One such option could be the galactolipid GOPO, which has been shown in randomised, placebo controlled clinical trials to significantly reduce arthritic joint pain and reduce consumption of paracetamol by 40 per cent. GOPO was found to have a positive safety profile and is able to be taken long-term.”
Managing joint pain
In The State of Musculoskeletal Health 2021 report, eight out of 10 people with musculoskeletal conditions said they want more practical support, such as tips about activity and pain management, to help them be more physically active. Many people want to work, but said they need the right support to find and stay in employment.
According to the most recent NICE guideline on Osteoarthritis in over 16s: diagnosis and management, published in October 2022, people with osteoarthritis should be offered therapeutic exercise tailored to their needs (such as local muscle strengthening and general aerobic fitness), including supervised sessions. Weight loss may improve the quality of life, physical function and pain in people living with overweight or obesity.
According to NICE, manual therapies should only be considered for people with hip or knee osteoarthritis and alongside therapeutic exercise. If pharmacological treatments are needed, these should be used alongside other nonpharmacological treatments, at the lowest effective dose for the shortest possible time. Topical NSAIDs should be the first-line treatment. If these fail to work, or are unsuitable, then consider an oral NSAID.
Poor sleep quantity and quality can have a significant impact on pain thresholds, and often needs to be addressed. A Deep Relief survey conducted in Autumn 2022 found that 79 per cent of Brits suffer from disrupted sleep when they’ve had joint or muscle pain. Half of the survey respondents claimed that it was a struggle to fall asleep because of their pain, with 66 per cent waking up in the night and 72 per cent feeling uncomfortable when lying in certain positions.
“Soothing pain can help avoid sleep issues,” says Sammy Margo, physiotherapist, sleep expert and an advisor to Deep Relief. “A study in healthy adults found that even moderate sleep loss induces inflammatory cytokines, something which 69 per cent of Brits are aware of, according to the latest Deep Relief research. Sleep deprivation also hinders emotional and cognitive abilities.”
“A survey found that 79 per cent of Brits suffer from disrupted sleep when they’ve had joint or muscle pain”
Looking to the future
In December 2021, a workshop organised by the Academy of Medical Sciences, the British Neuroscience Association, The Physiological Society and Versus Arthritis brought together a range of groups with an interest in chronic pain – including scientists, doctors and patients. A report on the workshop, published in December 2022, concluded that people with lived experience of chronic pain need to be at the heart of research partnerships to tackle the prevalent, and complicated, challenge of chronic pain management.
“It can be difficult to understand the variety and range of ways arthritis affects people in their everyday lives because the 200+ musculoskeletal conditions are all so different, just as we are all different,” says Colin Wilkinson, a research partner at Versus Arthritis. “I may find sitting still for long periods of time excruciating, whereas someone with a different condition might find sitting still very helpful.
“Without understanding the ways these conditions affect so many aspects of life, we can’t make progress in providing new and better ways to help people to live well with arthritis. We need lots of different solutions, and ways to help people work out what will help them.”
Fibromyalgia
In April 2021, NICE issued a guideline on the management of chronic primary pain in the over-16s. Fibromyalgia, a common type of chronic primary pain, is believed to affect up to one in 20 people in the UK. It most commonly develops between the ages of 25 and 55, but can affect people of any age.
Fibromyalgia causes widespread chronic pain. It varies in severity and may affect different parts of the body at different times. The pain is usually described as aching, stabbing or burning, but some people have numbness, tingling and itching sensations as well.
The condition also causes fatigue, insomnia, poor sleep quality, increased sensitivity to pain, difficulty concentrating, irritable bowel syndrome, anxiety and depression. The symptoms flare up and down, often triggered by factors such as stress levels, weather changes and activity levels.
Fibromyalgia is difficult to diagnose as there are no specific tests and the symptoms are similar to those in other chronic conditions. The exact cause is unknown, but a chemical imbalance in the brain seems to affect the way the central nervous system processes pain around the body.
The brain seems to misinterpret pain signals, causing overactivity of the nervous system. Initial triggering events may be an injury, infection or trauma. Research at King’s College London in July 2021 suggested that many of the symptoms may be caused by an autoimmune reaction, with antibodies directed against pain-sensing nerves.
According to the NICE guidelines on chronic primary pain, fibromyalgia should be managed initially with non-pharmacological approaches, such as exercise programmes, psychological therapies and acupuncture. Antidepressants such as amitriptyline may be used as a first-line pharmacological approach, rather than painkillers.
Self-help approaches such as exercise, relaxation and sleep hygiene are important, and some patients may be referred to local pain management services for a more-holistic approach. For further support and advice, customers with fibromyalgia can be signposted to Fibromyalgia Action UK (fmauk.org) and UK Fibromyalgia (ukfibromyalgia.com)
Views from the P3pharmacy category panel
Customers often don’t want to bother their GP about joint pain unless it’s very severe, so they will come to see the pharmacist to find out what we can do to relieve the pain, even if it’s while they wait to get a GP appointment. Typical questions we get are: How can I reduce the inflammation? Are there any supports that would help? What medications will work best? Generic painkillers tend to sell best for us, although Solpadeine is also popular. Topical ibuprofen gels do well, and Voltarol is our best seller. We also do well with heat treatment products such as Deep Heat.
Lila Thakerar, Shaftesbury Pharmacy, Harrow
This is important for us, although it’s not been as busy this year. I am wondering if more people are self selecting for this and perhaps buying products elsewhere now they know more about it. Voltarol is our top selling brand here. We also do well with Deep Heat roll-on and compression aids. We get asked advice about all kinds of joint pain, from tennis elbow to plantar fasciitis. Improving display is tricky as some of the products, such as heat patches, take up a lot of space. You have to do the best you can with the space you have available.
Lindsey Fairbrother, Goodlife Pharmacy, Hatton, Derbyshire
This is a very popular category for us and sales have increased in the last year. It’s not just an older person’s category – we find many of our younger customers are affected by joint pain, especially runners and those who play lots of sport. Ibuleve and Voltarol gels do well for us and also PureEssentiel Muscles & Joints Gel. We sell lots of supplements designed to promote joint health. Solgar does well, and also turmeric supplements, in particular the Wakaya organic turmeric brand. We place these products across the pharmacy, which helps improve sales for us.
Sarina Mughal, Day Lewis, Knightsbridge
OTC
In OTC